Optimal Steps for designing and implementing the extracurriculars through the integrative medical approach

Extracurriculars are those that fall outside the scope of the academic curriculum. The purpose of the work is to outline the steps of planning extracurriculars, practice these steps in the medical program, and evaluate these steps. Methods Using Kern’s steps with some modifications, we did some extracurricular reforms. Assessment of the current situation/needs and identification of gaps have been occurred by a questionnaire that revealed low students' satisfaction (36.1%) about the current extracurriculars with points of weakness that have been addressed in the improvement plan. A list of extracurriculars was prepared and aligned with modules and learning outcomes. Allocation of resources and implementation of these extracurriculars were performed. The evaluation was done through a questionnaire that was fulfilled by 404 students. Results Students' satisfaction was 66.8% in the second questionnaire compared to 36% in the initial questionnaire with a significant association. Further analysis of the respondents who revealed satisfaction showed that 95 out of 140 (67.8%) were high-grade achievers, 88 out of 134 (65.7%) for moderate, and 87 out of 130 (66.9%) in low-grade achievers. A comparison of the student’s satisfaction in the three phases revealed a significant p-value (0.004), but no significance in students' satisfaction within phases of the program between males and females. Conclusion Well-structured extracurriculars might contribute to the achievement of the mission, vision, and goals of the program. Extracurricular activities might be flexible and undergo periodic changes related to the nature of the curriculum. Following the cycle of developing extracurricular activities in designing, implementing, monitoring, evaluating, and reporting, the extracurricular activities will be more efficient in enhancing the learning climate and making the learning process more enjoyable, especially in a solid medical integrated curriculum.


Introduction
Extracurricular activities are those that fall outside the scope of the academic curriculum of university education. They comprised variables include students' satisfaction, students' performance and independent variables were goals, consistency with modules/ courses, timing, duration, facilities, allocation, transport, and availability of other logistic materials. 2) Designation, and implementation of the improvement plan through modification of kern' steps [25] for planning the extracurricular activities. 3) Re-evaluation of students' satisfaction with these extracurricular activities after implementing the improvement plan using second questionnaire with Likert scale. 4) Comparing the level of student satisfaction before and after the implementation of the improvement plan.
B. Study sample: The number of respondents in the initial questionnaire was 184, 116 male (63%) and 68 females (37%) ( Table 1), while in the reevaluation phase the number of respondents was 404 students representing all academic years for both male and female sections.

C. Data collection and statistically analysis
The questionnaire was designed as Likert scale containing four categories started from strongly satisfied to strongly dissatisfied and scored from 4 to 1. Data from the questionnaires were tested for reliability and placed into an Excel sheet before being analyzed statistically with SPSS version 25. Student t-test and ANOVA were run for inferential statistics.

Mechanism of designing of modified Kern' steps used in this study
The extracurricular committee completed several meetings to put the fundamental guidelines and regulations for planning, and designation of extracurriculars following the broad outlines of Kern's steps [25] with some modifications named as modified Kern's steps, these steps are described as follows: Step 1: Problem identification through revising the report of extracurricular activities of the previous years and identifying the area of weakness and strength.
Step 2: Assessment of current needs through a) Studying the updated form of program mission, vision, and learning outcomes. b) Questionnaire to identify the students' interests. c) Methods such as informal discussions, focus group discussions, direct observation of skills, and strategic planning session.
Step 3: Select extracurricular activities. This is done through: a) Brainstorming of extracurricular academic ideas b) Analyzing the questionnaire to list the students' interests c) Determining which type of extracurricular activity is required to achieve the mission, vision, and program outcomes, d) Selecting other extracurriculars that fit the students' interests like sports, arts, and poems, e) Activation of the students' club, f) Availability of resources including funding, learning, and logistics materials. g) Alignment these ideas or activities with the modules and courses, h) Variation of extracurriculars according to year, phase, and level of the study considering the degree of difficulty of modules/courses and its requirements and assessments.
Step 4: Key performance indicators and target levels: Determination of the key performance indicators and target levels for the evaluation process is essential as it monitors and measures the level of achievement and reveals the impact of these activities on students 'skills and all stakeholders included. The target levels should be revised periodically compared with internal and external benchmarks. KPIs can offer a regular way of monitoring proficiency in a variety of aspects of the learning and training procedure including extracurriculars [26,27].
Step 5: Implementation and monitoring of these activities: this is done through the following: a) Mapping of these activities through the longitudinal insertion of these activities in modules and courses of all phases and levels of the curriculum. Appropriate timing and hours are important. b) Distribution of the students into small groups with definite criteria for each c) Selection of faculty and staff members for guidance and observation, d) Participation of academic mentorship members. This will give more support and motivation to students to be more active participants. In addition, this will reflect more activation to career counseling, e) Invitation of eminent figures from the institute and community for some activities, f) Establishment of a rewarding system for active participants g) For good implementation, the extracurricular committee should: obtain permissions and facilities, identify, and allocate resources such as Table 1 Distribution of the degree of satisfaction concerning gender and program phase in the phase of assessment of current situation. personnel: faculty, administrative/secretarial, logistic supports, and funding which may be direct funding or opportunity expenses. In addition to academic, stakeholder, and professional society support.
Step 6: Evaluation: This step is a crucial step in the quality cycle and provides information to the extracurricular committees to start the process of improvement and reform. Evaluation results can be employed to assess achievement, meet external requirements, and function as a nucleus for presentations and publications. The evaluation can be done through a) Questionnaire: this can be fulfilled by all stockholders (students, peers, employers, partnerships, and community members) involved in the activity through fulfilling a wellstructured, valid, reliable questionnaire containing quantitative and qualitative sections b) Direct observation for all events and participants included in the activity.
Step 7: Reporting: A full detailed report for each activity should be done containing the number of active participants, beneficiaries, pros, cons, commendations, recommendations, and improvement action plan. These items were discussed in periodic meetings organized by the program hierarchy moderators and were documented and reported in the annual program report. These steps are represented in Fig. 1.

Identification of the problem and assessment of the current situation and needs
The extracurricular committee holds several meetings to study the program mission, vision, and learning outcomes, aiming to identify the extent of running extracurricular activities in achieving goals, mission, vision, graduate attributes, and values at both institutional and program levels. Aiming to identify the current situation, need, and identification of gaps, the followings have occurred: a) As the Albaha Faculty of Medicine program is community-based, the extracurricular committee in collaboration with the medical education/vice deanship for quality and accreditation, and the students club made a questionnaire to investigate the students' opinions about the extent of their need for extracurriculars by making a list and choosing the most activities that help in achieving the objectives of the program. Therefore, the questionnaire was designed to have quantitative and qualitative parts. The validity and reliability of the questionnaire were confirmed by two cohort studies with two-week intervals in between. After cohort studies, the questionnaire was distributed electronically to all students. b) Several visits to the selected places such as healthcare providers, large malls, sports, social clubs, and government service providers were done aiming to select the optimal environment for the implementation of extracurricular activities to achieve goals and outcomes.

Formation of an extracurricular list with identified goals and KPIs
After identification of the students' needs, the extracurriculars were listed covering varieties of activities including volunteer and social activities, international and national days, research, sports, and others. The identified extracurriculars have well-defined goals and objectives which were fully described and aligned with the program outcomes. In addition, key performance indicators and target levels have been identified for each activity. Examples of these activities are listed in Table 2.

Implementation phase
All extracurriculars were mapped in the schedule and aligned with modules. The required permissions, facilities, resources, and funding for each activity have been discussed, identified, and allocated.

Evaluation
The extracurriculars were evaluated using another Likert scale questionnaire to evaluate the degree of students' and personnel' satisfaction.

Initial assessment of current situation and needs using initial questionnaire
Analysis of the current situation using the initial questionnaire revealed that about 71 out of 184 (38.58%) showed satisfaction about the current extracurriculars, of these 42 out of 116 (36.1%), 29 out of 68 (42.6%) for male and female sections, respectively. Further details are discussed in Table 1.
Analysis of the qualitative part of the questionnaire reported the followings: lack of interest by some students and personnel; not aligned with some courses and modules, not suitable for the phase and level of the curriculum, the time specified for each activity did not correspond to the nature of activity and the desired objectives, the timing is not suitable as it is close to the time of assessments, interfere with student-centered activities such as problem-based and self-directed learning, costive for some students, preparation for some activities was much exhaustive, lack of cooperation with peers, and lack of orientation, guidance, and support.

Results of the questionnaire applied for re-evaluation stage
This phase was evaluated by the second questionnaire which was delivered electronically to 447 students representing all academic years for both male and female sections. Four hundred and four students responded to the questionnaire. The distribution of the current study of students was as follows: phase I (93, 23%) included 59 males, and 34 females, phase II (151, 37.4%) included 86 males and 56 females, and phase III (160, 39.6%) included 87 male and 73 female. In addition, these students were further subdivided according to their achievement into high 140 (34.7%), moderate 134 (33.2%), and low grade 130 (32.2%).
About 270 out of 404 (66.8%) were satisfied. Of these 159 out of 232 (68.4%), and 111 out of 172 (64.5%) for male and female, respectively with a significant difference p-value 0.0036. Regarding satisfaction and students' achievement, 95 out of 140 (67.8%) was of high-grade achievers, 88 out of 134 (65.7%) for moderate, and 87 out of 130 (66.9%) for low-grade achievers. By comparison of the students in the three phases, a significant P = 0.00 was obtained. These figures are further discussed regarding the male and female sections in Tables 3 and 4. There are no significant associations between students' satisfaction with extracurricular activities between males and females within the phases of the program. All data and P values are described in Table 4.
Furthermore, the students in phase I showed the greatest satisfaction among phases with significant difference (P = 0.00). The highest student satisfaction was found in male students representing phase II (70.9%), followed by female students in phase I (70.6%).  Table 3 Distribution of the students according to gender, phase of the program and students' achievement in the evaluation stage. The lowest student satisfaction was seen in the female section of phase III. The details are mentioned in Tables 4 and 5.
Using one-way ANOVA test for comparing the results of all phases including male and female sections on students' grades for both sections. A significant p-value was obtained, P = 0.00.
Further analysis for both male and female sections: Grade and students' satisfaction: in male section using t-test for the students 'grades with the degree of satisfaction, we found significance with a P = 0.00. Also, in female section, a significant P = 0.00.
Phase and students' satisfaction: Comparison between males and females regarding grades and students' satisfaction; a significant difference was obtained in phase I (P = 0.02), while no significances were obtained in either phase II (P = 0.43) or phase III (P = 0.11). In the male section: no significant differences were obtained between students' grades and students' satisfaction in phases I, II, and III with a P = 0.4, P = 0.98, and P = 0.096, respectively. Phases and students' grades in the female section: no significant differences were obtained between students' grades and degree of satisfaction in phases I, II, and III with P = 0.61, 0.82, and 0.84, respectively.
Phases and students' grade between male and female sections using t-test revealed that in phase I, a significant difference was obtained in students' satisfaction between male and female in low-grade students of phase I and phase III with a P = 0.02, 0.02, respectively. Otherwise, no significance was obtained.
Comparison of student's grade with that counterpart in all phases with students' satisfaction using ANOVA: (1) high grade in the male section; there is a significant difference with P = 0.04, while in the female section, no significance was obtained P = 0.25. (2) moderate grade, no significance was obtained either in male P = 0.18 or in female section P = 0.22. (3) low grade, no significant was obtained in both male and female sections P = 0.91, and 0.23, respectively.

Comparison between the results of both questionnaires
Comparison between students' satisfaction that resulted in the initial questionnaire with that appeared in the questionnaire of the evaluation stage revealed a significant difference with a P = 0.00 (Figs. 2 and 3).
In all tables, due to the asymmetrical representation of both male and female sections, the number and percentage were related to the total number of each section. In addition, the percentage of satisfaction was calculated relative to the number of students in each section. Furthermore, concerning the phase of the program, the percentage described in each raw was closely related to the number of students for each phase either in both male and female sections.

Discussion
This study showed that students' satisfaction with extracurricular activities was weak, while it increased significantly after the implementation of the improvement plan, to about 60%. This satisfaction is not only among students with high levels of achievement but among all levels. This means that this improvement plan was reflected not only in the students' satisfaction but also in the environment of the extracurriculars within the program.
In the current research, some students registered their objection to the time of extracurricular activities in the timetable, as well as the time specified for each activity, which may not be compatible with the nature of the activity. This observation is also found in the study of Whiteley & Richard [28] who found that a significant majority of teachers do not supervise extracurricular activities when they have no preparation time and recommended the importance of timing of extracurriculars in achieving their goals.
The time allocated for extracurriculars should be adjusted carefully. The direct relationship between hours of extracurriculars and student well-being has been recognized [29,30]. This may reflect a negative effect on academic performance if the students expended more hours participating in these activities, especially those of social interest that are time and energy-consuming [1]. Furthermore, an imbalance in academic requirements and extracurriculars may lead to depressive symptoms that in turn reflect on low academic achievement [31,32]. In this instance, good time management is recommended to decrease the low academic achievement and stress among the participants [33][34][35][36].
Participation in extracurricular activities supports the development of appropriate nonacademic talents that promote improving clinical skills and student performance [37]. Another study revealed that extracurricular participants have better skills in terms of  [20,38] and become more prominent in clinical years [39,40].
In the present study, we found that the sharing of students in extracurricular activities is increased in the clinical years than in basic years, reaching the highest in the 5th academic year. This contrasts with other studies which found positive associations between extracurriculars and stress among second [41,42], and third year [42,43] students owing to increased extracurricular activities and academic overload. This is due to the nature of the academic curriculum and the alignment of these activities with the modules in these years. So, educators should take into account the potential impact of preserving extracurricular activities on students' health when designing and planning academic courses [44].
The reform plan that was conducted in our program was three-dimensional that included extracurricular activities, learning and   teaching, and assessment methods. The plan was run in parallel in all dimensions and specific key performance indicators {KPIs) with internal and external benchmarks applied. The reform committee conducted several meetings, interviews with the students, faculty, academic staff, and stakeholders, and reviews of annual course reports, as well as reports of the extracurriculars, and psychometric analysis of all assessment methods. The obtained results were desirable, encouraging, and motivating, in addition to the high satisfaction of the students towards the comprehensive reform plan that was adopted.

Conclusion
The rate of student satisfaction with the activities has improved significantly after the implementation of the improvement plan, and satisfaction was high among all students, regardless of their academic achievement. This will inevitably lead to the achievement of the objectives of these activities, which will reflect positively on the improvement of the student's academic performance.
Extracurricular activities might be flexible and undergo periodic changes related to the nature of the modules and courses of the curriculum. Insertion of these activities within the modules must be matched with the learning outcomes and might consider the degree of difficulty of running modules and assessments.
Following the cycle of developing extracurricular activities in designing, implementing, monitoring, evaluating, and reporting, the extracurricular activities will be more efficient in enhancing of learning climate and make the process of learning more enjoyable, especially in a solid medical integrated curriculum. In addition, time management of these activities is essential to avoid adverse effects such as low academic activity and low student performance.

Limitations of the study
The different number of respondents for the initial and re-evaluation stages may be explained by the appearance of a strong incentive for students to participate in the second questionnaire, after implementing the reform plan, and this is considered an indirect success for the reform plan, and this incentive led to an increase in the number of students participating in the second questionnaire, which created a difference between the number of students in the first and second questionnaires. Accordingly, the percentage was used, not the number, in the comparisons made in this study. So, this difference in participants is considered as a limitation of the study.